The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: DIR

The similarities are that they (1) Both see autism as a neurobiological disorder whose course can be significantly affected by the early caregiving environment; (2) Both work with very young children, often 2-years old or even younger; (3) They both organize their models around a linear developmental framework that refers to “normal development”, in other words – at this age the typical child should have this competency, and then at this other age, he should be able to do this; (3) They both include the parents – but to varying degrees; (5) They both have a prescribed set of techniques that the therapist has to master; (6) They both use videotape as a teaching tool; (6) They both track progress through the accomplishment of specific developmental competencies that are set forth in their writings (such as the achievement of language goals or goals in pretend play).

The differences are that (1) ESDM derives from ABA (the behavioral method that Lovaas introduced in the 60’s), though not DTT (discrete trial training), while DIR derived from observations that the young children in a disadvantaged population had a high incidence of developmental disorders; (2) The ESDM is a manualized treatment that involves the clinician to chart goals and results for each session, and the DIR – while requiring adherence to specific techniques – does not require a specific number of particular responses from the child within a time frame; (3) ESDM has impressive empirical evidence to demonstrate its effectiveness including a very large n (660) and following the children from 6 months to 36 months; DIR is only just now starting to do efficacy studies (there are some long term follow up studies but only one empirical study that I know of, following children 12 months; (4) ESDM really emphasizes starting at age 2 and though DIR also likes to start early, it often doesn’t start that young; (5) ESDM likes to maintain the “coherence” of the intervention by NOT involving other disciplines like OT and speech, believing that this intervention is comprehensive enough in itself, whereas DIR from the beginning has worked with an interdisciplinary team; (6) ESDM emphasizes language acquisition as perhaps its critical first goal, whereas DIR emphasizes the establishment of joint attention first, believing that language acquisition will follow; (7) DIR emphasizes visual spatial orientation more than ESDM, believing that this is frequently disturbed in ASD children and interferes with social engagement; (8) The DIR technique emphasizes using affect and the relationship (joint attention) more than ESDM; (9) DIR almost always works by coaching the parents and not the therapist working directly with the child, whereas, ESDM often has the parent in the room but has the therapist working directly with the child and the parent watching – then they have separate sessions to teach the parents.

Evidence that DIR and ESDM are learning from each other or at least coming closer together is as follows: (1) Sally Rogers talked about the importance of the ESDM initiative to train parents; this is similar to the original technique of DIR of coaching parents. (2) Although Sally Rogers emphasized the coherence of the treatment and how other disciplines were not involved in order to accomplish this coherence, some of her slides included involving OT and speech specialists, so I imagine they are included if only as consultants or advisors. (3) Serena Wieder talked about the effort to obtain validation in empirical research for DIR. (4) The DIR intervention is presented as designed to suit the individual child – in this way distinguishing it from ESDM, yet the intervention model follows a prescribed path that takes the child and parent from one level to the next in a linear progression. (5) Although Dr. Wieder also presented DIR as attending to the inner world of the child, she did not show us examples of this in her films. (6) In addition, the DIR training does not seem to produce clinicians – excellent though they tend to be – who are familiar with this particular domain child psychotherapy; that is, DIR clinicians generally are skilled at working with parent and child at the lower “levels” of development as defined by the DIR model, but not so much at the higher level of symbolic function.

Dr. Wieder talked about her original collaboration with Stanley Greenspan. She wanted to do outreach to underprivileged population. They started long term study of an underprivileged population to answer the question of how do you know that a child is “on track”? The first thing they learned was they had to deal with regulation and shared attention. They then realized they needed to learn more about language development and sensory integration and they brought in specialists in these fields. Then what the infant brings into the world, the individual differences. They created an intervention for children with developmental disorders, primarily ASD – DIR. “D” is for development, “I” is for individual differences, and “R” is for regulation.

Wieder states that the basis for development and for treating autism is developing reciprocal relationships between parent and child. DIR introduced a major paradigm shift in intervention from a focus on behavior to one on affect and relationships. The idea is affect is central to learning and that emotions drive early cognitive development. The approach involves treating relationships and not just the child. It assumes that every child has an inner world even if he or she cannot express it, that everyone has individual differences and therefore needs an intervention that specific to him or her, that an interdisciplinary approach is necessary, and that competencies come from experience instead of from training. These features of DIR distinguish it from the ESDM model as it is described. DIR proposes a structure to bring together a step-wise model of the developmental process with the individual features of the child, and features of the environmental, including the parents. There are 6 “core developmental stages or processes called The Functional Emotional Developmental Levels”.

Wieder also points to the biological/neurological origin of autism, referring to autism as a disorder of neural connectivity that interferes with the connection of affect and intention to the child’s ability to sequence actions and also to relate, communicate, and think (Just et al, 2004, 2007). When sensory motor processing and challenges in language comprehension and visual spatial knowledge derail development, emotion must be brought into the intervention as early as possible to strength the connection between sensation, affect, and motor action.

Dr. Wieder stresses that DIR initially emphasizes the relationship with the parent. She says that DIR has influenced the field; now behaviorists use developmental concepts and the two groups may be coming closer.

I recently received a neuropsychological testing report on a little patient of mine who has developmental problems in the general category of autistic spectrum disorder. The report was exceptional in its careful attention to detail – in the description of the tests, in the account of the child’s performance on the tests, and in the way it set out the implications that these subtest results had on the child’s learning and more general development. I was very pleased. Then I looked at the recommendation section, and I was disappointed. That is not to say that the recommendations were incorrect. They were detailed and comprehensive. However, they included recommendations for multiple specialists.

Some of these specialists could provide services at school through the school system; the family is fortunate in that the city where they live makes many special needs services available to children in the school system. However, too many of the recommendations for specialists – such as a CBT therapist and an autism specialist in addition to my psychotherapy with the child – will not be provided by the school. This presents a dilemma for the family. Either the family finds the time and money to pay for these specialists and to take the child to these additional appointments, or the family lives with the worry that they are not giving the child all of what he needs – with long-term negative consequences.

I believe strongly in the team approach to the treatment of children with autistic spectrum disorders (ASD) or pervasive developmental disorders (PDD). However, I also believe in paying attention to the “family economy”, meaning the resources in time, money, and emotional reserve that the family has at its disposal. I have led a number of parent groups for parents of “quirky” children, and I have witnessed the anguish of parents who were trying to make decisions about allocating limited resources to the care of their ASD or PDD child.

Also, perhaps because my husband is an economist, I am sensitive to the pull of the marketplace and the influence that has on recommendations for treatment. I am not suggesting that all these specialists do not believe that what they are offering is the very best and in fact necessary for the health of the children they treat. I am suggesting, though, that each specialty has a financial incentive to compete for patients. In addition, it is sometimes true that the more defined and therefore narrower perspective of a specialist may have a negative effect for two reasons. The first is that they may be less well prepared to integrate the various aspects of the child’s treatment than a therapist with a more general approach, and the second and related reason is that they may duplicate various aspects of the treatment, sometimes causing confusion and certainly costing more.

I do not hide my bias for a psychodynamic therapist to be at the center of the treatment of these children. That is my training and my conceptual model. However, I have other reasons for suggesting this plan. The first is that children with ASD and PDD essentially have problems with development, and developmental science now teaches that development occurs in the context of a relationship. Of all the therapeutic disciplines, psychodynamic therapy is the one that primarily emphasizes the therapeutic relationship. The second reason is that psychodynamic therapists aim to make meaning of the particular child’s experience, and to do that they must search for the unique personhood of that child and try to join it. This begins, as it does in normal development, with a shared focus of attention and proceeds to the sharing of complex experiences of affectively charged symbols. It is only through the energetic building of a position of mutual understanding and collaboration that the therapist can help the child build new developmental capacities.

The dynamic therapist, though, must not limit herself to the verbal narrative and symbolic play of these children. Instead, she must learn – especially from her O.T. colleagues, but also from child trauma researchers – how to help the child regulate himself, and then work with the parents to help them continue the work at home. She must focus relentlessly on the child’s agenda and support it by recognizing and joining it, then nudging it slightly forward by making contributions of her own, in a repetitive but flexible manner. This approach shares a lot with the DIR floor time method; I have learned a great deal from floor time practitioners.

The therapist must also comment on the relationship between herself and her patient, and acknowledge patterns that may repeat themselves with parents, teachers, and peers. She must network with the parents and other caregivers and clinicians as frequently and consistently as possible. Through these therapeutic interventions, the therapist and child make links between the child’s inner world – emotions and fantasies – and his body (physiological arousal state and experience of body in action), and between his inner world and the outside world of objects and other people. In essence, the psychodynamic therapist can fulfill many of the roles of other specialists, while keeping the meanings of the child’s inner world always in mind. This is what I hope to do in the Cornerstone project beginning in September and what I also try to do in my own clinical practice. While I am learning more and more about ASD and PDD from current research in these fields, I don’t call myself an autism specialist, because what I am learning about these children applies and enriches my work with all my patients.

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.